medical claim

MEDICAL CLAIM FORM ADDITIONAL FORMS: (301) 731-1064 Have your Social Security Number ready. ELECTRICAL WELFARE TRUST FUND 4601 Presidents Drive - Suite 300 - Lanham, MD 20706-4832 Fax: 301-731-1065 • info@ewtf.org IMPORTANT: Claims MUST be filed within one year or they will be denied. Attach provider’s insurance form (i.e., superbill, HCFA form) THIS SIDE MUST BE COMPLETED BY THE MEMBER INQUIRIES PHONE: (301) 731-1050 Have all papers available when you call. PART A Member Information Member Name________________________________________________________________________________ Last First Initial Home Address _______________________________________________________________________________ The Eligible Electrical Worker’s Social Security Number: ______ / ______ / ______ _____________________________________________________________________________________________ Home Phone ___________________________________ Work Phone _________________________________ Email address _______________________________________________________________________________ Member DOB _____/_____/_____ Marital Status circle one: Married Employer __________________________________________________ Single Separated Divorced Birthdate Widowed Marital Status PART B Patient Information Definition of a Dependent: Your lawful spouse that resides with you, and any unmarried children who are fully dependent on you for support and maintenance. For more information about dependents see the plan booklet. Patient Name ___________________________________ _____/_____/_____ ___________________ Relationship to Member _____________________(If child over 19, full-time student? circle one: Yes No) Patient address ______________________________________________________________________________ Does patient have other health coverage? Circle one: Yes No If yes, identify: ___________________________________________________________________________________ Attach copy of EOB Telephone Number ____________________________________________________________________ Is patient covered under Medicare? Circle one: Yes No If yes, attach Medicare Explanation of Benefits from carrier. PART C Authorizations I verify that all information contained in this form is true, correct and complete to the best of my knowledge. I authorize any licensed doctor, practitioner of the healing arts, hospital, clinic, health related facility, pharmacy, government agency, insurance company, group policyholder, employee or benefit plan administrator having information as to the care, advice, treatment, diagnosis or prognosis of any physical or mental condition, or the financial or employment status of the participant named below, to provide this information to the Electrical Welfare Trust Fund. Under the privacy provisions of the Health Insurance Portability and Accountability Act of 1996, you may be required to complete a separate Authorization Form, or Personal Representative Form (in the case of a non-spousal representative). PRINT NAME ____________________________________________________ DATE _____________ Signature of Participant/Guardian ________________________________________________________ Assignment of Benefits Is payment to be made directly to Provider ____YES ____NO If provider of service shows assignment and balance due, payment will be made to provider. If no assignment is checked, payment will be made to provider. If your claim is the result of an accident or injury, fully complete the back of this form. PART D If the patient’s visit to a doctor, emergency room, urgent care center or other facility is the result of an accident or sudden illness, please provide the following information. Date of Injury/Accident/Onset: Was a Police Report Filed: YES (attach copy of report) NO Location of the Accident or Where the Injury Occurred (provide complete address) Describe the accident fully or how the injury occurred (attach a separate sheet of paper if necessary) List any other individuals involved: Name of their insurance co. Insurance Co. Telephone No. Name & Address of your Insurance Company: Will medical expenses be provided by anyone (an insurance company or individual) other than you? ❑ NO ❑ YES – List Names ______________________________________ ______________________________________ ______________________________________ NOTE: No benefits are payable for work-related injuries or illnesses or for injuries that are caused by a third party such as another motorist. The rules of this plan provide that the responsible third party, or the injured person’s private insurance, such as homeowners or motor vehicle insurance, be primarily responsible for payment for medical expenses and lost time. This plan will “advance” or “loan” benefits to pay bills as they come in. Any “advances” or “loan” of benefits are to be repaid to EWTF once the third party, whether an individual, employer, or insurance company has made payment. To secure such repayment, EWTF requires that the individual and their attorney, if any, sign a promissory note and repayment agreement before benefits are advanced. I hereby certify that these statements are complete and true. Signature ______________________________________________________________________ Date ______________________ Notarization is required ONLY for motor vehicle accidents and Workers Compensation. County of: ______________________________________________ State of: ___________________________________________ On this __________ day of ____________________________ , ___________________________, personally appeared before me ___________________________________________ , who, being duly sworn, subscribed to the foregoing in my presence. Notary Public _______________________________________ seal